Cautionary Hints and Tips

Endotracheal tube related cautionary hints and tips...

• After intubation turn the face of the patient on the side which is kept on arm board, based on the surgeon’s preference, with right arm out. The problem does not exist except for over extension of arm beyond 90º. Prevent it by putting the IV stand on the head end side of the arm board. Hyper abduction, arm below the table level and head rotated on the opposite side can lead to bronchial palsy. In my observation, maximum number of accidents occur with head rotated on left side (right mastoid)
  • due to linking of the ET over the airway or the bite block and
  • excessive oozing during surgery.
  
  
• In oedentous (patients with beard) patients and infants do not depend on sticking tapes to the ET. Always use a tape or bandage to tie the tube round the face. Stitching tapes easily give way and come out due to salivation, making it easy for the ET to come out.
  
• On operation on neck where extension is needed with a bolster under the shoulder, tape the eyelids with small tapes to prevent the eyelids coming apart due to gravity and draping, which pulls the upper eyelid down towards the table causing exposure keratitis and corneal ulceration. Fix the tube only after final position is given with bolster under the shoulder. If fixed earlier to the angle of the mouth, the tube can come out of trachea .
  
• In ophthalmic procedures, to prevent the sterile drapes from becoming wet, surgeons put a waterproof sheeting on top. In patients who are not intubated and the airway is not in place, patients find it difficult to breathe. Fresh air cannot enter under the waterproof plastic sheet and the patient becomes restless. Carbon dioxide accumulates under the drape and they start hyperventilating. This can be prevented by putting a 1 meter (approx.) corrugated hose under the drapes, which is communicating with the theater air. Ventimask is a must.
  
• Always fix the ET in patients with hyperextension of the neck after the position is given and it is confirmed that the ET is in the trachea and not abutting at the commissure or has come out.
  
• Keep a watch on the arm kept by the side of the patient is well tucked in with a tape keeping the arm close to the body. A loose arm and the surgeon or assistant leaning against the table can press the ulnar nerve against the edge of the table.
  
• Extravasation of 5% Thiopentone or other irritating drugs can cause median nerve palsy. Use 2.5% solution and inject under vision. Inj. Diazepam outside the vein can cause sloughing and ulceration. In the event of extravasation, inject normal saline at the site to dilute the extravasated drug and its effect.
  
• Confirm that the injection to be given is in the vein and not an abnormal artery.
  
• For a patient in prone position check and make sure that the abdomen is free from the operation table and is well supported on bolsters. Make sure that the face and head are in a comfortable position and well supported and that the ET is not kinking and is well fixed with a tape or bandage to the head. Manual IPPR should be continued till the final prone position is given. If connected to a ventilator, check it manually for good ventilation and then switch on the ventilator.
  
• For a patient in a sitting position, involve the neurosurgeon in fixing the head. After fixing check the ET, and tie the ET to the head support to prevent it from slipping with movements of head during surgery.
  
• After cannulating a vein do not forget to remove the tourniquet. A case is recorded where the anesthesiologist forgot to remove the tourniquet and went on injecting more and more of 5% Thiopentone to meet the requirement for surgery. The tourniquet was detected when the patient was shifted to the ward. In the evening when the surgeon visited the patient it was found that arm, forearm and palm had turned black, pulse good volume and all muscle movements normal. After slight exfoliation of epidermis the extremity was normal. The cause– diffusion of Thiopentone into the tissues with intact tourniquet; fortunately it was a venous tourniquet.
  
• In all patients operated under tourniquet, make a note of the tourniquet time and see that it is removed at the end of surgery. Check again when the patient is being moved to the ward.

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Premedication schedule never works due to many variables

Premedication in private practice does not work except with the first case in the morning when anaesthetist and surgeon work at the same nursing home. The scheduled time is disturbed due to:

• Transport difficulties
  
• Either the surgeon or anaesthetist delayed in the previous case
  
• Patients relatiives not present
  
• Patient sent for special exam for ureteric stone or some X-ray investigation needed
  
• Delay by the theatre staff, equipment

Hence one can depend on premedication on the 1st case only. The rest of the schedule has to be conducted with IV premedication + inductions. Injection Atropine, which was prescribed ½ hour before, does not help in modern practice. It was a must for open drop ether anaesthesia where suppression of salivary secretion was essential. Injection atropine of dryness and some may even start thinking that some extraordinary complications is taking place due to drying and rapid action of the heart and feverish sensation. The olden days premedication for stealing the thyroid in thyrotoxicosis do not apply as they are never taken on table unless sympathetic activity is totally suppressed with anti thyroid drugs.
With IV medication one is assured of
Full administration of drug in system (leaky syringes used by nurses)
Only one injection prick patient feels. This is important in children, as they are very uncooperative for the 2nd injection.
Premedication for infants either by oral or by injection has to be given by ½ hours before induction is by inhalation method. Delayed action like I.V. atropine may not act immediately and appearance of secretion due to endotracheal tube narrow the air passages by secretions.
For patients who are anxious a 10 mg. Diazepam at night or even a tab of diazepam early morning will alleviate the problem.
In patients where induction dose of Thiopentone is likely to be dangerous heavy premedications or basal narcosis is a must, like mitral stenosis patients. Avoid atropine for tachycardia it produces. In very sick and poor risk patients it is better to avoid any premedication.
In some public hospitals the order of patients to be taken for surgery is not known and hence the ward sister gives the injection atropine to all patients at 7.30am as patients are scheduled for surgery at 8.00am (which normally does not start till 8.30 or 9.00 am). The system is followed for years together as anaesthetist insist on atropine ½ hour before. They do not mind delaying the induction till ½ hour is over after injection of atropine is given. I do not understand the rationale behind this plan. Is it because you do conduct less cases in the day and leave early for home? Or is it to show your domination? Nobody is bothered about the suffering of the patient.
Vagolytic action of atropine in pharmacologic doses to prevent vagal arrest is doubted and hence insistence of giving it ½ hour before surgery is sheer ignorance, as IV atropine acts immediately it can certainly replace IM as drying effect is not necessary for IV induction and intubation. If it is given that the 1st drug to be followed by Thiopentone or even mixed with thiopentone (sometimes produces precipitate which dissolves) also acts before scoline and prevents the Cholinergic effect of scoline.
In one infant for congenital cataract the surgeon had prescribed atropine drops in the eye. He did not order oral or sub cut atropine. On arrival we found that atropine drops had produced complete systemic effect with facial flushing tachycardia and dry mouth. Induction with open drop could be take up immediately without injection atropine
Premedication Schedule – never works in private practice except the first case. As you are likely to be delayed, surgeon’s arrival, preparation of OT due to previous operation.

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Anesthesia on Demand

My idea of “Demand Anesthesia” is not liked by many senior anesthesiologists including my late teacher Dr. Bhojraj. Their objection to this technique is that the patient responds in between which is likely to result in adrenaline secretion and may result in hypertension, ventricular fibrillation and arrest. Demand anesthesia is a vigilant anesthetic technique which needs continuous watch of the depth of anesthesia by signs of light anesthesia like

• (a) tachycardia
• (b) some muscle movements
• (c)screwing of the eyebows and forehead.

When any one of the signs is exhibited you are supposed to administer additional dose of Thiopentone till the reflex is suppressed. Far too often appearance of signs of anesthesia means you have to give additional sedatives and analgesics like Diazepam and Pethidine or Pentazocin or even stronger pain relieving drugs. All one is supposed to do is the balance the quantity of drug given and reaction of the patient to the stimuli. People are really worried about the cumulative effect of drug in post op period. But the patients are comfortable. Their O2 saturation does not fall and if by any chance the effect of drug persists as trickle of O2 though the nasal catheters tides over. This technique has been tried in many nursing homes without Boyle’s apparatus to deliver Nitrous Oxide-Oxygen and inhalational anesthesia. In my practice I have extensively tried this technique especially in cystoscopic procedures and orthopedic procedures like major fractures in very aged patient. Surgeons are very happy with the procedures since they find their patients awake and comfortable in post-op period. Vital parameters (signs) are stable and well maintained. Though anesthesiologists do not believe in this technique, my advice to them is “to see and then believe”. Those who have seen this technique are converted and like the technique. In a difficult situation it comes in handy.

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#31-35: Private Practice Anesthesia- Do’s and Dont’s

31. Keep a casual watch on theatre asepsis and let the surgeon know at an appropriate time. Observe the colour changing labels on the drums, and instruments supplied in between.
    
32. Always talk to the surgeon first in high risk cases where a death on table is likely. When surgeon agrees, talk to the relatives along with surgeon. Obtain consent, then only start.
    
33. Patients with respiratory obstruction, difficulty in breathing, Ludwig’s angina trismus: In these cases do not even venture to give sedation. Never think of giving anaesthesia unless the airway is secured. Topical anaesthesia, awake intubation, tracheostomy done, guided blind intubation or flexible intubating bronchoscope used to intubate are your options.
    
34. In places with very hot climate and during summer allow patients to have a glass of plain water one hour before surgery. This is especially for children.
    
35. Do not order your premed for adults. Give IV at the induction only in sepcial cases. Order the premed at the exact time. Do not give only Ketamine to an adult. Do not give Diazepam alone for patient with pain. They become incoherent and unmanageable. Same rule follows for Scopolamine for elderly patients.

#36-40: Private Practice Anesthesia- Do’s and Dont’s

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#16-20: Private Practice Anesthesia- Do’s and Dont’s

16. Never be in a hurry to send the patient back to the ward if the procedure was done under a muscle relaxant. If in doubt try IPPR; if permitted the patient needs reintubation or IPPR with mask till he is completely reversed.
    
17. Rising BP; not the colour or consciousness, indicate inadequate reversal. Transfer only if the BP is steady and the patient is conscious.
    
18. All patients who have received muscle relaxant (long acting) must be reversed with at least 0.5 to 1 mg. Prostigmin for even a small dose of muscle relaxant.
    
19. Patients having long acting spinal anaesthetic drugs must be under observation with written instructions for maintenance of BP in post-operative period.
    
20. In patients with known full stomach or even expected full stomach induce with head up tilt, remove the Ryle’s tube after proper suction in different positions. Oxygenate with 100% oxygen. Do not ventilate after Scoline. Ask the surgeon to give tracheal pressure, introduce the laryngoscope blade only when the patient is fully relaxed and intubate. Study your position for intubation (take a flat stool to stand on if necessary) with head up tilt.

#21-25: Private Practice Anesthesia- Do’s and Dont’s

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